Experts offer guidelines on circulatory support devices

An international and multidisciplinary team of experts has developed guidelines to assist physicians who treat patients with mechanical circulatory support devices (MSCDs). The executive summary with recommendations was published in the February issue of the Journal of Heart and Lung Transplantation.

The team—co-chaired by David Feldman, MD, PhD, of the Minneapolis Heart Institute, Salpy V. Pamboukian, MD, MSPH, of the University of Alabama at Birmingham, and Jeffrey J. Teuteberg, MD, of the University of Pittsburgh—wrote that the guidelines were designed to address issues of long-term use with the goal of patient discharge from the hospital.

“Currently, management of patients with MCSDs has been guided by individual clinicians and center-specific protocols,” the authors wrote. “There have been few randomized studies to guide patient selection and care of the MCS patient. Short-term success with MCS therapy largely depends on patient selection, surgical technique and post-operative management. Long-term success depends on physician and patient engagement in excellent care of their device and personal health.”

Five task forces developed the recommendations, many of which are level of evidence C or consensus agreement. The recommendations are organized by task force.

Task Force 1 addressed patient selection and risk management prior to permanent pump implantation, with recommendations on evaluating and classifying patients and on ethical dilemmas.

Task Force 2 covered patient optimization before device implantation, with recommendations on multidisciplinary care, education and psychosocial support; management of cardiac and noncardiac risk factors; patients with relative contraindications; informed consent; and ethical issues.

Task Force 3 handled intra-operative considerations and immediate post-operative care in the intensive care unit (ICU), with recommendations for anesthesia, implantation techniques, explantation techniques, complex anatomic considerations and early post-operative management in the ICU.

Task Force 4 addressed inpatient management during the post-operative phase, once the patient is out of the ICU and during readmission to the hospital, with recommendations about psychosocial support and suitability for discharge to home; common reasons for hospital readmission; and approaches to their management.

Task Force 5 offered recommendations on long-term outpatient care, including management by a multidisciplinary team that includes cardiovascular surgeons, advanced heart failure cardiologists and specialized MCS coordinators and assessing the patient's social network and caregivers.

The 38-member team of cardiologists, cardiac surgeons, MCS coordinators and others was convened by the International Society for Heart and Lung Transplantation. The executive summary of the guidelines is available here.